SUBACUTE WRITTEN EXAM - ortho.pdf

SUBACUTE WRITTEN EXAM The assessment will utilise short and long cases, still images and/or videos. In some tasks, students will discuss appropriate evidence-based management plans through the identification of impairments/activity limitations/participation restriction and by applying information fr...

SUBACUTE WRITTEN EXAM The assessment will utilise short and long cases, still images and/or videos. In some tasks, students will discuss appropriate evidence-based management plans through the identification of impairments/activity limitations/participation restriction and by applying information from objective assessments. Students will be asked to modify (progress or regress) management plans based on additional information. In addition, the effect and evidence for common medical and non-medical management will be assessed. Students will prepare/justify parts of a typical inpatient rehabilitation workload. When working through the cases, students will apply material learned through workshops and masterclasses to answer multiple-choice, short answer and extended response questions. The exam will consist of multiple choice, short answer, T/F, fill in the blank questions and medium-length answer questions. There are some general questions (approx. 30 marks) and cases (approx. 10-15 marks each). Table of Contents ORTHOPAEDIC CONTENT – WK 1-4......................................................................... 2 General questions.........................................................................................................2 Specific questions........................................................................................................8 Lower limb....................................................................................................................................... 8 Spine.............................................................................................................................................. 14 Upper Limb.................................................................................................................................... 17 NEUROLOGICAL CONTENT – WK 6-13................................................................... 20 Case-based questions................................................................................................ 20 Stroke – Intro - Masterclass......................................................................................... 22 Stroke – Intro - Workshop............................................................................................ 28 Stroke - Bed mobility, Sitting, STS, Standing - Masterclass........................................... 32 Stroke - Gait and stairs part 1 and 2 - Masterclass........................................................ 33 Stroke – UL - Masterclass............................................................................................ 35 Multiple Sclerosis - Masterclass.................................................................................. 38 Parkinson’s Disease – Masterclass.............................................................................. 42 Life as a Rehabilitation Physio - Masterclass................................................................ 47 Secondary and non-motor impairments - Online module............................................. 47 Using technology in rehabilitation............................................................................... 48 b ORTHOPAEDIC CONTENT – WK 1-4 General questions General questions 1. Discuss/identify (from a case) the indications (as a treating physiotherapist) for doctor referral (or not) following different surgeries (i.e. progressive neurological symptoms, infection…) 2. Discuss evidence for surgical, non-surgical and conservative management for the conditions covered in the Masterclasses Condition Surgical Conservative ACL Found no difference Cross bracing looking between knee fx, pain and promising – more healing @ 3 RTS between rehab + early month mark repair or rehab + delayed Contraindicated for those with repair repairable meniscal tears, At 2 year surgical between osteochondral lesions or than conservative but not obstructive meniscal tears statistically meaningful 50% of delayed optional Surgery better option for surgery group will go for those with knee instability surgery d/t dissatisfaction @ 18 months Less active/older patients more likely to be satisfied with conservative tx  risk of secondary injuries e.g. meniscal Meniscal Bucket handle tear → Majority of tears follow tear can’t straighten conservative approach knee/locked → requires successfully surgery to fix Meniscal repairs follow a Flap tear → pinches in a much more conservative squat – potentially for rehab than meniscectomy surgery Criteria based progression Arthroscopy + preferred over time based meniscectomy/Meniscal Stronger evidence to avoid repair/ surgery if have OA as well Ankle # Weber B (in line with Weber A (distal to syndesmosis – stability syndesmosis) – conversative varies) - may require ORIF typically indicated – typically or just CAM boot don’t need to be casted, just Weber C (above orthoses syndesmosis, syn is Weber B (in line with ruptured - unstable) – syndesmosis) - sx or CAM boot ORIF required for 6 wks  Achilles Insertional tear Midportion tear could have rupture No difference in terms of either surgical or conservative rehab and limited If want conservative, need to difference for healing (tiny be immediately placed into PF bit lower risk of re- Heel raises rupture) Hip/Knee Third line treatment Conservative/exercise first line OA Very successful surgery – treatment -  pain,  function 80-90% no residual pain Second line treatment = + Surgery better if mod- meds severe OA – px meds, affects sleep/QoL/ function Hip # Intracapsular Extracapsular Displaced Non-displaced > 60 yrs < 60 yrs Spine Decompression +/- fixation for spinal stenosis and surgery for surgery cervical radiculopathy – some evidence favouring surgery and other for conservative – not enough difference Shoulder Arthroscopic subacromial Progressive exercise vs best surgery decompression - surgery practice advice, vs with or better for shoulder pain without corticosteroid and function compared injection for rotator cuff with no treatment but disorders - Progressive placebo similar - exercise not superior to best therefore, maybe it is the practice for improving advice and sling protocol shoulder pain and function post-surgery than the CSI provided no long-term surgery benefit Subacromial vs Therefore, education is greatly arthroscopy for shoulder important. (1 education impingement - No session is as beneficial as difference at 24 months progressive exercise program) Treatment of non-traumatic rotator cuff tears – physio vs acromioplasty and rotator cuff repair - No significant difference between the 3 interventions 3. Outline the different surgeries in the same detail as the Masterclass. Condition Surgery Post op rehab Meniscus Arthroscopy = camera in 1-2 weeks knee joint + → WBAT aim to be FWB by Meniscectomy = 5/7  damaged cartilage is → Aim to reduce pain and trimmed away swelling eg ice Arthroscopy + Meniscus → Emphasise full knee repair = tear is sutured extension together depending on → SLR, glute bridges, ½ the location of the tear squats, heel slides (outer not inner) 2-4 weeks condition of the → Progress exercises meniscus 4-8 weeks Recovery time is longer → Increase resistance in meniscus repair → Initiate running program, compared to initially on meniscectomy and post spot/trampoline op is much more → Goal is to return muscle conservative strength + endurance, return to running 8-12 weeks → When can run 4-5km in a straight line can start agility drills → Return to competitive sports Surgery Details ACL reconstruction · Surgery type used will impact pt recovery →in particular site of graft · Autografts > the Allografts · Patella tendon graft  Middle 1/3 of tendon  ↑ pF knee pain (kneecap, kneeling)  ↑ post-op stiffness  ↓ knee laxity compared to other methods   risk of developing PFP &  stiffness at end ROM Ext · Hamstring tendon graft o Easier Sx to perform o ↓ knee pain/stiffness post-op, ↓ hamstring strength o ↓ incision and faster recovery o ↑ laxity/potential graft lengthening o H/S graft tend to get some H/S pain at 4 weeks - weaker graft and looser end result · Quadriceps tendon graft o Middle 1/3 of quadriceps tendon  o Fixation not as solid o ↑ post-op knee pain o ↑ laxity/potential graft lengthening o Quads graft weakest and high risk of re- rupture only used if re-ruptured a second time · Allografts o Usually from cadavers o No pain as occurs in autografts o ↓ Sx time, incision, stronger bony fixation, ?graft elongation? o ↑ risk of infection, ↑ failure rate Meniscus Arthroscopy o Camera to look with knee joint Arthroscopy + Meniscectomy o Damaged cartilage is trimmed away Arthroscopy + Meniscus repair o Sutured together o Depends on § Type of tear, location of tear (outer not inner) condition of meniscus § Time for recovery is longer than meniscectomy Hip Replacement · Type of replacement o THR Vs hemiarthroplasty o Long stem o Short stem o Joint resurfacing · Types of approach o Anterior, lateral, posterior · Type of fixation → cemented vs un-cemented TKR · Consists of tibial, femoral and patella components Hip # surgery Spinal surgeries · Decompression o Laminectomy § Remove back part of vertebra § Foraminotomy Remove bone around the foramen Relieves ‘pinched’ nerve · Discectomy o Remove part/all of disk · Fusion  RC tear repair · Arthroscopic RC repair o For smaller procedures/tears and ‘just to have a look’ o Less invasive o Camera guided, Sx through 2–3 small slits o Increasingly larger Sx’s occur using arthroscopic procedures o Mini-open RC repair · Open RC repair o Large or complex tears or reconstruction (tendon transfers) o Potentially an incision/detachment of the deltoid o Better see and gain access to the torn tendon 4. Discuss indications for surgery. When stated in the Masterclass notes, break these into absolute and relative indications Condition Absolute indication Relative indication Ankle # Weber C – unstable - Weber B – stability syndesmosis varies ruptured Achilles rupture Insertional tear Midportion tear THR Pain: OA RA Post-traumatic arthritis Avascular necrosis Developmental abnormalities of hip Limited success with conservative Trauma Hip # Displaced # + > 60 yrs = THR or hemi Non-displaced, < 60 yrs = internal fixation ACDF Progressive cervical Radiculopathy that has myelopathy (when failed to respond to the spinal cord is conservative treatment being compressed – for at least 6/52 there is no Recurrent conservative radiculopathy treatment for this –  only general nerve Progressive compression can you neurological deficits → try conservative first)  numbness and Certain infections weakness Traumatic instability Severe pain Red flags Patient preference Lumbar Spine Fusion Similar to ACDF Severe pain Unstable # Progressive spondylolisthesis Shoulder surgery Atraumatic, degenerative full thickness cuff tear Adhesive capsulitis Failed conservative tx Presence of serious pathology e.g. tumour Acute traumatic full thickness cuff tear Traumatic dislocation +/- Hill sachs +/- bankhart lesion Previous failed shoulder surgery Some proximal humerus # Some partial thickness tears OA – long term RC arthropathy Frequent/recurrent dislocation – needs stabilisation 5. Logical exercise/task progression/regression for potential exercises/tasks at different time points following surgery for LSF, THR, Gr III Achilles tendon rupture, RC tear (NOTE: YOU ARE NOT EXPECTED TO MEMORISE A WHOLE REHAB PROTOCOL BUT TO MODIFY EXERCISES BASED ON A CASE / PROTOCOL / EXERCISE PERFORMANCE IN A LOGICAL WAY) Condition Exercise LSF Day 1 Teach precautions, log roll, breathing techniques, gait Progress Wall slides, standing rows/presses, balance Bridges, supine marching, squats, deadbug, planks, cardio THR Day 1 rehab Ankle pumps, quad sets, glute squeeze, heel slides, iso hip Abd FASF walk 5 m  Progress distance,  mobility aids,  independence Grade 3 Achilles tendon Early rehab -  inflam,  ADL’s, maintain leg strength rupture Circulation - Toe scrunches, toe spreading, ankle pumps ROM – knee F/E, hip F/E/Abd/Add Strength - SLR, clams, quad contraction Phase 2 – FWBing with crutch,  DF to neutral slowly ROM as above Strength – as above + bridges Bike Phase 3 – allow splint to come off, early calf strength TB ankle exercises, calf raises Proprioception Bike Phase 4 - Sport Gym based resistance exercises – SL squat, leg press Ecc heel drops off step RC tear Pendulums, scap depressions, PROM shoulder movt AA shoulder – F, ER, Abd Active F/Abd 0-90 deg, AA > 90 deg, IR Isometrics Resistance – low rows, TB Push up a. Identify patient exercise compensations from a picture 6. Outline factors that result in better/worse outcomes following surgeries. 7. Describe appropriate patient Mx, for different surg based on a post-op protocol. a. I.e. Surgeon says patient can/can’t perform x,y,z. What exercises/movements would you/would you not perform? i. I expect you to be able to do this for a novel condition not necessarily covered in the masterclass and apply relevant principles we have learned. Specific questions Lower limb 8. List and briefly describe the risk factors for an ACL injury Young age (16 peak) Participation in sports Variations in bone morphology (+20 deg knee E)  Neuromuscular control – lig strength, collagen) Genetic Hormonal Female 9. Outline/Describe the different types of meniscal and ACL surg and briefly state the implications to recovery in the same detail as the Masterclass notes/discussion. Meniscal Surgeries Arthroscopy → camera Arthroscopy + Meniscectomy Damaged cartilage is trimmed away Arthroscopy + meniscus repair Sutured together Time for recovery is longer than meniscectomy Depends on type of tear, location, condition of meniscus ACL Surgeries/Grafts Autografts → tissue from patients own body – more cost effective Allografts → tissue from donor – most commonly used for revision surgery Patella tendon Middle 1/3 of tendon  patellofemoral pain (kneeling)  post op stiffness (particularly into E)  knee laxity compared to other method (strongest graft and  risk of re-injury but harder to rehab as stiff) Hamstring Easier surgery to perform  knee pain/stiffness post op,  hamstring strength  incision and faster recovery  laxity/potential graft lengthening (compared to patella) Quadriceps Not done much. Middle 1/3 of quad tendon Fixation not as solid  post op knee pain  laxity/potential graft lengthening Re-rupture still high Allografts Usually from cadavers No pain as occurs in autografts  surgery time, incision, stronger bony fixation  risk of infection,  failure rate 10. List the different management considerations esp. with reference to the Weber fractures classification + displaced/non-displaced fractures in the same detail as the Masterclass notes.  Stable non-displaced # Mx: o Weber A #s ▪ Typically, don’t need to be casted ▪ Treated in stabilising ankle orthoses ▪ Early function and WBAT ▪ Syndesmosis intact ▪ ROM exercises as tolerated o Non-type A #s ▪ CAM boot ▪ Over 6/52, the patient WBAT in boot ▪ Orthosis stays on at night ▪ ROM exercises as tolerated 11. Describe the management of Weber B fractures (Kortekangas et al 2019) in the same detail as the Masterclass notes. Week Goals Exercises 0-6/52 NWB or PWB (50-75%) 0-2/52 – NWB post depending on surgeon protocol 2-4/52 – WBAT with crutches ORIF of involved LE at 6/52 AROM for ankle and foot within DF to neutral at 6/52 pain – ankle pumps, inv/ev, toe Control oedema crunches, alphabet Towel stretches in DF 6-8/52 WBAT Gait training level surfaces with post > 50% AROM in all planes proper tibia advancement, quad ORIF involved ankle and subtalar activation, symmetrical WBing joint Stationing bike Control oedema Grade 1-2 joint mobilisations ankle Minimise complications and subtalar joints Maintain optimal bone/soft PROM into restricted ranges tissue healing environment Continue DF stretches TB DF/PF/inv/ev in open chain Seated heel raise and BAPS Manual resistance in open chain for DF/PF/inv/ev/multiplanar motions Leg extension/curls/press Wall stretch with knee flexed and extended 8+/52 Full ankle and subtalar AROM, post flexibility ORIF Restore gait on level surfaces, hills, stairs Full return to function 12. Compare surgical vs conservative management for gr III Achilles tendon surgeries (use the prep work to help you also). Surgical Conservative Insertional definitely surgery Midportion maybe Midportion maybe Rehab 1 year Rehab 1 year  risk of re-rupture (somewhat)  risk of infection Re-ruptures must be surgically repaired Cheaper Risk of infection, risk of clot  risk of re-rupture 13. From a case, argue the most appropriate approach 14. From a case, outline considerations for rehabilitation from a brief patient history for Achilles surg. Exercises performed slowly and smoothly Brace worn until removed by doctor (with ankle in PF) NWB for first 2/52 Massage foot to  swelling Risk of re-rupture jumping from a height Epidural vs GA Sports insurance vs patient paying? Pain levels Steps at home? Work? Transport? Social help Very active person typically Ensure patient can use crutches/mobility aids provided Ensure understands NWB status Showering How to put on boot 15. Describe (when required) the precautions and length of time of precautions following surgery for ORIF and THR (posterior approach).  ORIF THR NWB first 2 weeks No hip flexion > 90 F (including bending to pick stuff up) Boot required with heel lifts (1 Limit hip IR/ER – inc twisting removed every 4 wk for 10 wk) Avoid DF until 6/52 Cross over midline (inc crossing leg) RTS 6 months Limit hip ext (only for anterior approach) 16. Outline the pathophysiology and risk factors of OA, fracture (i.e. hip) and conditions mentioned in the masterclass OA Fracture (hip) Pathophys Not simply a wear and tear Causes: disease Trauma It is a disease that affects Tumour the whole joint – meniscus, Paget’s disease (affects long labrum, cartilage, term joint health) subchondral bone, Stress # synovium, inflammation, muscles Risk factors Age (40+) Osteoporosis Sex (female) Family history Overweight Low body weight Prior joint injury (e.g. ACL) Cigarette smoker Hard physical work Overuse in spare time Family history of OA Lack of physical activity CAM (for hip OA) – 10x  risk of hip OA a. Describe the differences in Mx between ORIF and THR surgery as well as the exercises/weight bearing required post-op ORIF THR Mx Types of fracture Type of replacement Displaced THR or hemiarthroplasty Nondisplaced Long stem (more femur px Location of fracture post op) NOF Short stem (feel more like Base of NOF normal hip) Intertrochanteric Subtrochanteric  Procedures Joint resurfacing (younger pt, Internal fixation when acetabulum and NoF is Arthroplasty (THR, hemi, okay. Place cap of HoF) sliding hip screw) Type of approach Anterior (most common – Will perform internal through TFL) fixation in most cases Lateral (Gmed) Only will perform THR/hemi Posterior (Gmax) if > 60 yrs and displaced Type of fixation Cemented Uncemented (generally this one) Exercise 2xdaily, total of 60 min per Introduce → ankle pumps, day, 16 weeks quad sets, glute squeezes, STS, stepping, foot taps, heel slides, isom hip Abd, step on + off a block, active hip Abd treadmill, side-lying leg lifts, Day 1 → SOEOB, transfer to knee ext/quad sets, ankle chair, walk 5m DF/PF Progress mobility status and distance walked WB status WBAT? Surgeons’ choice but typically WBAT using FASF D/c typically with crutches b. Outline the logical progression of walking aids/weight bearing status for THR FASF → frame → crutches → walking stick → nil WBAT → FWBing 17. Describe what you must check prior to seeing a patient on day 1 following Sx and why it is important to check these. Surgeons notes – type of procedure may dictate Mx Baseline ax prior to surgery? – may indicate what Pt may be able to achieve today PMHx – any barriers to tx today Contraindications/precautions WBing status Vital signs Pain tolerance, meds 18. Outline/Discuss the differences/implications in conservative Mx vs surg Mx for Extrascapular femoral fractures  Typically cast is most likely appropriate compared to surgery for extrascapular Would depend on whether the # was displaced, the cognition of the Pt to follow the precautions 19. Briefly outline the evidence for traction following hip # In summary, while traction was historically used, modern evidence suggests limited effectiveness, and early surgical intervention is preferred for better outcomes. 20. Describe recommendations to avoid surgical revision following TKR Pursue low-moderate intensity/impact exercise’s e.g. walking, swimming, moderate activity to  strength Purpose of TKR is to allow patients to resume normal activities not to go back to high intensity exercise Avoid running, contact sports, heavy lifting 21. Describe the main points in the manuscript by Skou et al. comparing TKR +PT vs PT for moderate to severe OA. TKR seen as more effective vs PT alone, especially for mod-severe OA But greater no. of serious adverse effects from the TKR groups (as expected) PT after surgery = 1 hour, 2x/week for 12 weeks – focus on strength, control, functional activities, proprioception 22. Outline conservative Mx strategies for patients with knee OA without comorbidities Single joint (only knee OA) + no comorbities o Biomechanical interventions o Intra-articular corticosteroids o Topical non-selective NSAIDs o Walking stick o Cox 2 inhibitors (selective NSAIDs) o Paracetamol If comorbidities/multi-joint → no non-selective NSAIDs Spine 23. What are the precautions and instructions (and must not do’s) 0-14 days post ACDF Sx Precautions and instructions o Cervical collar if requested by surgeon – up to 2/52 o Consult with doctor  ▪ Warm to touch, incision (drainage, separation, new bruising, infection ▪ New numbness or tingling in hands/fingers ▪  pain in neck/shoulder/arm ▪ New weakness of either arm, hands, legs or loss of balance Must not do’s o Pick up or carry anything heavier than 1.5L of milk with affected arm o Sleep with arms overhead or on stomach o Lift anything above shoulder level o Spend all of your time in bed o Perform strenuous exercise/activities o Get surgical site wet until healed (approx. 10/365 post-surgery so long as it is not red/draining) Do’s o Sleep on firm pillow to help support neck o Change positions frequently (might time exempted) o Gradually increasing walking time – do not get too tired o Do not drive until approved 24. Briefly describe the evidence for surgery for cervical radiculopathy Absolute indications → cervical myelopathy (spinal cord compressed) Relative indications for ACDF surgery o Radiculopathy that has failed to respond to conservative treatment for at least 6/52 o Recurrent radiculopathy o Progressive neurological deficits →  numbness and weakness, impacting QoL o Severe pain 25. NOTE: It is expected that you will be able to answer the issues (from the cases) presented in the Masterclass. 26. Outline factors that may influence the length of time of the precautions IMPORTANT to note that bone remodelling and healing takes time – do not go hard and fast with physio Factors that affect bone healing time: o Cigarette smoking o Age o Nutrition o Comorbidities → chronic disease, diabetes o Steroid use o Radiation and chemotherapy Excessive motion at the fusion site can lead to excessive callus formation and delay of the reparative process  Do not exceed the mechanical limits of the newly forced tissue – overstressing tissue may result in tissue injury + delayed healing. Goal is to strengthen the newly formed connective tissue This phase can take many years and may never present on imaging Placing appropriate stress on the soft tissue and bone in graded increments will promote proper soft tissue/bone growth/development 27. Describe the precautions and length of time of precautions following LSF Precautions o Bending, lifting (>5kg), twisting, (over) extending o Prolonged sitting > 30-60 min o Limit pushing, pulling o Avoid driving Length of time = 6 weeks 28. Provide advice to a patient when they are struggling to do movements (this will be embedded within a case) BRP Bend, roll and push 29. Describe indications for further referral / testing, sometimes emergency (pseudoarthrosis / DVT / infection / cauda equina syndrome) RED FLAGS NOT TO BE MISSED o Indications of cauda equina syndrome o Urinary retention o  anal sphincter tone o Pain radiating to both legs o Severe low back pain o Sensory loss – legs, inner thighs, back of legs, saddle anaesthesia o Sexual dysfunction Pseudoarthrosis o Failed attempted fusion – pedicles collapse and drop disc space o ‘strange’ and persistent neurological and pain symptoms Infection 30. Compare the outcomes of surgical (LSF) vs conservative management for spinal stenosis.  31. Briefly outline the types of conservative management. Physical therapy Medications Activity modifications Upper Limb 32. Outline the precautions in 0-4/52 following moderate to large RC repair (with entry through the deltoid) Week 1-4 No push/pull/lift No shoulder Ext/horiz Abd/IR/OH No active deltoid muscle contraction 6-8/52 No stretching or sudden movement No supporting BW No sleep on affected side Wound mx, keep dry Week 5-8 No heavy lifting/carrying No excessive HUB or motion No support BW Avoid stretching Week 8-13+ No resisted ex for 9/52+ Isotonics after 10/52 33. Outline the conclusions for surgery using the papers included in the Masterclass (in the same detail as the masterclass)  Arthroscopic subacromial decompression for subacromial shoulder pain o Sx had better result than no treatment but not clinically important – sling protocol? Subacromial decompression vs arthroscopy for shoulder impingement o Decompression no better than arthroscopy at 24 hours Progressive exercise vs with or without CSI for rotator cuff disorders o Exercise no better than a education session – for shoulder pain and function o CSI no long term benefit Physio vs acromioplasty vs rotator cuff repair o No significant distance between the 3 interventions o Physio important and should be used for non-traumatic cases 34. You may be provided (within the exam) the Mean difference, 95% confidence intervals and clinically worthwhile effect of a particular surgery vs sham or physiotherapy and you must provide an explanation of the result 35. In academic language OR; 36. In patient centred language to a patient that would like to know the difference in outcome between surgical and physiotherapy management. 37. List and briefly describe the causes for RC injury Generally, 4 different styles of painful shoulder based on Physiotherapy assessment Referred or related to another cause (e.g. cervical, thoracic, abdominal, neural, vascular tissues) (e.g. herniated disc presenting as shoulder pain) Primarily related to a stiff shoulder (e.g. frozen shoulder, OA) – restricted range Due to instability (e.g. multidirectional instability, subluxation, dislocation) Related to the short tissues (painful/weak) (e.g. rotator cuff, bursa) + we still need to exclude serious pathology and determine the relationship between the shoulder pain and other prognostic factors (e.g. comorbidities) 38. List and briefly describe the factors that affect rehabilitation following RC repair (12 factors). Note that you may be asked about this in relation to a different joint 12 factors that affect rehabilitation following surgery 1. Surgical approach Open and mini-open procedures and ALL arthroscopic If the deltoid muscle is detached o Therefore, no active deltoid muscle contraction allow for 6-8/52 If arthroscopic – minimal/no deltoid involvement in surgery 2. Size of tear Small ( 5cm) Small tear most common > 5cm poorer outcomes,  no. of tendons involved Retracted tears – greater mobilisation of the muscle o Greater post-operative failure rate o More conservative protocol 3. Tissue quality Good, adequate, poor Quality of the muscle, tendon, bone Poor quality from smoking, alcohol etc 4. Fixation method 5. Location of tear Supraspinatus, infraspinatus/teres minor (IR stretches it), subscapularis (ER stretches it) Tears that extend to involve posterior cuff structures (infra and teres) require greater protection and restriction in excessive shoulder IR motion (strain on site) o Also requires slower progression with shoulder ER strengthening exercises Subscapularis tears o Restrict the amount of ER motion until early tissue healing has occurred 6. Type of tear Crescent shaped (small U-shaped tear), U shaped (moderate, large), L shaped, retracted o Retraction occurs proximally – difficult repair due to tissue tension – rehab should be more conservative 7. Mechanism of failure Acute traumatic (5%), gradual wear (95%) Stiffness is higher following acute traumatic tears. And when other procedures such as SLAP are performed concomitantly – rehab more aggressive in these patients 8. Timing of surgery Earlier surgery better than delayed surgery – quicker rehab 9. Rotator cuff tissue Health of surrounding structures – play vital role in establishing humeral head quality anterior and compression and dynamic humeral head stability posterior to the tear If quality is fair→ poor, consider a more conservative post-surgical rehabilitation site protocol 10. Patient e.g. age, smoking, T2DM, workers comp characteristics Older patients → tissue quality  and tendon have larger tears and more complex abnormalities Workers’ comp → require 2x more time to return to work Active patients pre-injury have better outcomes post-surgery 11. Access to care Training at home or training with physio – physio generally have better outcomes than home based programs 12. Physician Conservative vs aggressive – will affect rehab time philosophical approach 39. Describe why scapula exercises are important and understand when you would use these/advise these in rehabilitation o Purpose of rotator cuff ▪ Movement/mobility ▪ Force ▪ Proprioception ▪ Stability 40. Outline the factors that result in better and worse outcomes following TSR surg o Younger age: Patients under 65 generally recover faster and regain more function. o Good preoperative shoulder function: Patients with less severe preoperative disability and better muscle strength tend to have better outcomes.  o Early rehabilitation: Following a structured physical therapy program post-surgery promotes quicker recovery and better shoulder mobility. o Surgeon experience: Outcomes are often better when the procedure is performed by an experienced orthopaedic surgeon specialized in shoulder replacements. o Non-complex conditions: Patients with primary osteoarthritis (non-inflammatory) tend to have better results compared to those with more complex conditions. o No significant comorbidities: Healthy patients with fewer or no other medical conditions typically recover better. 41. NOTE: It is expected that you will be able to answer the issues (from the cases) presented in the Masterclass. NEUROLOGICAL CONTENT – WK 6-13 Case-based questions Understand and describe the essential components in healthy people for rolling, SOEOB, sitting, dynamic sitting, sit to stand, standing, dynamic standing, walking, reaching and manipulation. Rolling Trunk rotation Neck rotation/flexion Protraction shoulder Hip F → push E Knee F Adaptive strategies → grab bed and pull intact arm, wriggle, use unaffected leg to hook and lift affected leg SOEOB Lateral trunk F, shoulder abd, elbow E Lateral neck F Legs lifted and lowered over side of bed Adaptive strategies → neck flexion/rotation, excessive pushing up on intact arm, hooking intact leg under affected leg, fall backwards Sitting Back ext and core activation → maintain posture Quads, glute, PF’s Need to be able to maintain CoM when reaching/UL tasks Ankles plantar grade Feet and knees close together Weight evenly distributed Flexion of knee/hip under trunk Head aligned with trunk Adaptive strategies → widening of BOS, shift weight to intact foot/butt, Flex forward when task requires body weight to be shifted